| NPI | 1740160134 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WI 8597) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 15391) |
| Enumeration Date | 2025-09-05 |
| Last Update Date | 2025-11-10 |